Understanding Medicare and Immunotherapy: Does Medicare Cover This Cancer Treatment?

• Immunotherapy is a form of cancer treatment that helps the immune system fight cancer. It can be used in tandem with other cancer treatments.

• Does original Medicare cover cancer treatments? Yes, so long as it is deemed to be medically necessary. This includes immunotherapy. Medicare Advantage plans will also cover

• Medicare supplement insurance may help with out-of-pocket costs associated with cancer treatment such as deductibles, coinsurance, and copays.

For Medicare beneficiaries, receiving a cancer diagnosis can be a frightening and stressful experience. From coordinating what their health insurance will pay to what they are responsible for out-of-pocket costs to understanding what cancer treatments are best for their specific diagnosis, there are many factors to navigate.

There are various cancer treatment services available today. The treatment approach taken will be dependent on the type of cancer as well as the prognosis. For example, breast cancer may have different treatment approaches than lung cancer and so on. 

Potential types of cancer treatment include chemotherapy, radiation, cancer surgery, and immunotherapy. But will Medicare cover cancer treatment? Yes, Medicare covers cancer treatments when they are deemed medically necessary. This article will focus on Medicare and immunotherapy treatment in particular.

Immunotherapy is a type of cancer treatment that assists someone’s immune system fight cancer cells. Immunotherapy is a biological therapy, using medications that trigger an immune response that will kill cancer cells. Cancer vaccines may also be used during immunotherapy. These vaccines bolster the immune system response to cancer cells.

Can Immunotherapy Be Used With Other Types of Cancer Treatment?

Immunotherapy can be administered in combination with other types of cancer treatments such as chemotherapy and radiation. Immunotherapy may also be used following cancer surgery.

There are various types of immunotherapy, and many new versions are being developed and studied. Different types of immunotherapy are best for certain types of cancer. 

Note: Learn more about what type of immunotherapy is best for a specific cancer diagnosis at this resource from the American Cancer Society.

Immune Checkpoint Inhibitors

Immune checkpoint inhibitors are cancer medications that trigger the immune system to attack cancer cells. Some examples of immune checkpoint inhibitors include: 

• Pembrolizumab (Keytruda)

• Nivolumab (Opdivo)

• Cemiplimab (Libtayo)

Note: Learn more about immune checkpoint inhibitors at this resource.

Chimeric Antigen Receptor (CAR) T‑Cell Therapy

CAR T‑cell therapy uses specific white blood cells, known as T‑cells, to fight cancer cells. CAR T‑cell therapy is a type of cell-based gene therapy.

Note: Learn more about CAR T‑cell therapy at this resource.

Cancer Vaccines

A cancer vaccine differs from preventive vaccinations in that they do not prevent cancer but make the immune system destroy cancer cells.

Note: Learn more about what a cancer vaccine is at this resource.

Different portions of the federal Medicare program will be responsible for specific treatments. Original Medicare coverage is comprised of three parts: Medicare Part A, Medicare Part B, and Medicare Part D. Medicare Part A will cover inpatient services, Medicare Part B will cover outpatient services, and Medicare Part D will cover prescription drugs. 

According to the Centers for Medicare and Medicaid Services, Original Medicare covers various types of medically necessary cancer treatment supplies, services, and prescription drugs under these Medicare Parts, as well as under Medicare Advantage plans.

Medicare Part A 

Medicare Part A is Medicare’s hospital insurance. Medicare Part A covers inpatient services after beneficiaries have met their Part A deductible for the benefit period. 

When it comes to cancer treatments, Medicare Part A covers: 

• Inpatient hospital stays

• Skilled nursing facility care

• Home health care

• Hospice

• Blood

• Some costs for clinical research studies

• Surgically-implanted breast prostheses after a mastectomy (surgery must have taken place in an inpatient setting)

Note: Learn more about Medicare costs and inpatient hospital services at this resource.

Medicare Part B

Medicare Part B is Medicare’s medical insurance. Medicare Part B covers outpatient services after beneficiaries have met their Part B deductible for the year. 

When it comes to cancer treatments, Medicare Part B covers: 

• Doctor’s visits

• Many chemotherapy drugs

• Some oral chemotherapy drugs

• Radiation treatments

• Diagnostic tests

• Durable medical equipment (DME)

• Outpatient surgeries

• Mental health services

If Medicare Part B doesn’t cover a particular cancer drug, a Medicare Part D plan may provide coverage for it.

Note: Learn more about Medicare costs and outpatient hospital services at this resource.

Medicare Part D

Medicare prescription drug coverage is known as Medicare Part D. Medicare prescription drug plans cover most prescription medications as well as some chemotherapy treatments and drugs. Under Medicare Part D, these cancer drugs may be covered:

• Oral drugs used for chemotherapy 

• Anti-nausea drugs

• Various other cancer medications used throughout treatment (i.e. pain meds)

Medicare Advantage plans, also known as Medicare Part C or MA plans, are supplemental Medicare plans. Medicare Advantage plans are offered by private insurance companies that are approved by Medicare. 

MA plans combine Medicare Part A and Medicare Part B coverage. Many Medicare Advantage plans also often include additional benefits such as vision, hearing, dental, and prescription drugs. That said, interested beneficiaries should always consult their insurance company in question to confirm extra benefits.

Medicare Advantage Plans & Immunotherapy Coverage

Because Medicare Advantage plans include Medicare Part A and Medicare Part B by default, a Medicare Advantage plan will cover immunotherapy treatments, so long as the Medicare Advantage plan in question also includes prescription drug plan coverage, since immunotherapy often requires various cancer drugs.

Medicare supplement insurance, also known as Medigap or MedSupp, are supplemental Medicare plans that help ​“fill in the gaps” of Original Medicare. It may help pay some of the costs of cancer treatment. 

Medigap policies are sold by private insurance companies and help pay some out-of-pocket costs such as deductibles, coinsurance, and copays.

Note: Learn more about Medigap plans at this resource.

Immunotherapy drugs can be expensive. As well, Medicare does not cover Keytruda and other immunotherapy medications. That said, there are many programs from the federal government, as well as state governments, that help people get the prescription drugs they need to treat cancer. 

Programs that may help with immunotherapy cancer treatment costs include:

• Merck Helps

• Head and Neck Cancer Fund

• Good Days Patient Assistance Program

• PAN Foundation Patient Assistance

Most of the programs require applications. Visit their official websites to learn more. 

How long does Medicare cover immunotherapy?

Medicare will cover immunotherapy for as long as medically necessary. However, after 60 days of inpatient treatment, patients will be subject to coinsurance costs under Medicare Part A.